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Clinical 2.0 > VTE > Flashcards

VTE Flashcards

1
Q

which is the only factor not generated by the liver

A

factor 8

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2
Q

where is factor 8 synthesized

A

by vascular endothelial wall and released into the blood stream

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3
Q

what happens to factor 8 in the bloodstream

A

cleaves into 2 separate components

  1. factor 8C coagulant material which goes to the intrinsic pathway of fibrin
  2. factor 8 vWF factor which is used in the formation of platelets
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4
Q

what does thromboaxane A2 do

A

platelet aggregator

vasiconstrictor

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5
Q

how is TXA2 formed

A

in platelets cox enzyme converts arachodonic acid to thromboxane a2

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6
Q

what do prostacyclins do

A

platelet anti-aggregator

vasodilator

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7
Q

how are prostacyclins formed

A

in the blood vessel wall AA converted by COX to PGI

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8
Q

what 3 things are produced by platelets

A

TXA2
serotonin
adp

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9
Q

what does the GPIIb/IIIa receptor complex do

A

binds to fibrinogen and brings platelets together

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10
Q

what causes platelet activation

A

TXA2, thrombin, collagen

increased cystolic calcium

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11
Q

what happens at the GPIb/IX receptor

A

vWF binds and adheres the platelet against the wall of collagen

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12
Q

factors predisposing to bleeding

A

open vessel
platelet defects
pro clotting factor deficiences

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13
Q

what is added to the test tube of patient plasma for prothrombin time

A

thromboplastin and calcium

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14
Q

more than ___ seconds is suggestive of a defective ______ pathways in prothrombin time

A

greater than 12 seconds

defective extrinsic and common

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15
Q

prothrombin time is sensitive to reductions in which factors

A

1, 2, 10, 7

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16
Q

warfarin reduces the synthesis of which factors

A

2, 7, 9 , 10

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17
Q

which factor has the short half life**

A

factor 7

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18
Q

why might a thrombotic state still be present even after you see an increased prothrombin time right after initiating warfarin

A 
factor 7(extrinsic) very short half life so will decrease the PT right away 
still some facotr 2 or 10 around and can be activated by the intrinsic pathway (not measured by PT)
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19
Q

INR and aPPT are not altered by _____ (4)

A

thrombocytopenia
defective platelets
ASA
NSAIDS

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20
Q

INR and aPPT are prolonged when

A

fibrinogen level is low

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21
Q

what is added to the patients plasma in the aPPT test

A 
activating agent (mimics collagen exposure) 
calcium
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22
Q

> _____ suggestive of a defective _____ in aPTT

A

> 30seconds

defective intrinsic and common

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23
Q

aPPT test is sensitive to reductions in which factors

A

1,2,10 (common)

9,11,12 (intrinsic)

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24
Q

heparin moa

A

immediately accelerates the binding of antithrombin 3 to activated forms of factors 2,9,10,11,12 thus inactivating them

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25
Q

when are heparin effects seen in aPPT

A

immediate

max effects after 6 hours (4.5 half lives of heparin)

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26
Q

relationship between inr and PT

A

thromboplastins different in different contries do get different prothrombin times
INR is standardized throughout every country using the PT and the international sensitivity index

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27
Q

INR formular

A

PT(patient)/PTc(mean time for your lab control) ^ISI (international sensitivity index)

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28
Q

whats the normal INR range

A

0.9-1.1

treated patients: 2-3

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29
Q

what are white thrombi

A

arterial thrombi
primarely made of platelets
ex. coronary artery thrombosis - stroke

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30
Q

what are red thrombi

A

venous thrombi
primarily fibrin and RBC and a small platelet plug
ex, deep vein thrombi - on a plane

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31
Q

what is th ehemostatic balance

A

balance between clotting (procoagulants) and bleeding (anticoagulants)

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32
Q

what is type A hemophilia

which test would it show up in

A

deficiency of factor 8C, but normal8vWF “classical”

aPPT test

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33
Q

what is type B hemophilia

A

deficiency of factor 9 “christmas disease”

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34
Q

what is von willebrands disease

A

diminished factor 8 VWF but normal facotr 8

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35
Q

what is disseminated intravascular coagulation

A

simultaneous clotting and bleeding

commonly seen with severe sepsis

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36
Q

what happens with clotting factors and anticoagulants in severe liver disease

A

factor deficiencies cause bleeding - decresed hepatic synthesis of factors 1-13 except 8
also decreased synthesis of antithrombin, plasminogen and alpha 2 antiplasmin
have anti and pro coagulant imbalances so can clot or bleed
DIC may also occur

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37
Q

what is thrombocytoopenia

A

decreased platelet count from either a decrease in bone marrow production(gradual) or due to increased peripheral destruction (more rapid)

38
Q

what is heparin induced thrombocytopenia

A

allergic reaction to heparin

platelets fall 5-10 days after becoming prothrombic

39
Q

name 3 thrombogenic risk factors

A 
obesity 
over 40 yoa 
malignancy 
immbolization 
major surgery 
acute MI 
multiple trauma
40
Q

unfractionated heparin will not work if have a deficiency in what

A

antithrombin 3

41
Q

LMWH examples and mechanism

A

enoxaparin,dalteparin, tinzaparin

binding wiht antithrombin 3 and neutralizes activated forms of 10a

42
Q

why does warfarin initially increase clotting

A

depletes the synthesis of protein C - a anticoagulant

dont give alone for the first few days

43
Q

how do asa/nsaids work

A

inhibit TXA2 syntheiss by acetylating COX thereby decreasing platelet aggregability

44
Q

tenecteplase moa

A

thrombolytic (dissolves clots)
increased fibrinolysis
converts plasminogen to plasmin

45
Q

desmopressin moa

A

increased release of factor 8-vWF thus enhancing platelet aggregability
pro platelet aggregation

46
Q

bivalirudin and argatroban inhibition

A

factor 2a inhibitor

47
Q

dabigatran inhibition

A

factor 2a inhibitor

48
Q

rivaroxaban, fondaparinux, apixaban inhibition

A

factor 10a inhibitor

49
Q

deep vein thrombosis signs and symptoms

A

unilateral
warm swollen
painful
starts in calf then moves up to femoral positive homans sign

50
Q

what is the homans sign

A

pain upon dorsiflexion of the foot

51
Q

clinical presentation of pulmonary embolism

A

tachypnea (rapid breathing)
chest pain
dyspnea
tachycardia

52
Q

test performed in pulmonary embolism and why

A

chest xray
ekg
blood gases
used to rule out other causes of symptoms, all should be negative

53
Q

based on the chads score what drugs should be used

A 
0 = asa only 
1 = asa OR DOAC or warfarin 
>2 = DOAC or warfarin
54
Q

DOACs recommended for all forms of non valvular afib and what valvular forms

A

mitral regurgitation
aortic stenosis
aortic regurgitation

55
Q

do not use doac (direct oral anticoagulant) in which conditions

A

mitral stenosis

prosthetic vlave disease

56
Q

patients with prosthetic heart valves are at increeased risk of what

A

developing valvular thromboembolism

57
Q

warfarin inr target of ___ for valves in aortic position and no risk factors for thromboembolism

A

2.5 (2-3)

58
Q

warfarin INR target of ____ for patients with valves in the nitral position and risk factors for thromboembolism

A

3 (2.5-3.5)

59
Q

drug recommendations for bioprosthetic valves

A

lower risk for systemic embolization
assa 75-100mg
for the first 3-6 months after bioprosthetic vlavue surgery warfarin inr of 2.5 (2-3)

60
Q

when to check aptt and platelets when on heparin

A

check aPTT every 6 hours initially and adjust to maintain desired range within first 24 hours
check platelet count daily

61
Q

when should tou stat warfarin and stop heparin for coagulation disorders

A

start warfarin mg day 1 and adjust according to INR goal
stop heparin after at least 5 days of combined therapy and when INR is greater than target for at least 2 consecutive days

62
Q

starting and stopping for heparin and warfarin in patients with a major pulmonary embolism or iliofemoral vein thrombosis

A

run heparin for up to 10 days and start warfarin after a delay of 4 days

63
Q

parameters to monitor for therapy for UFH,LMWH, or warfarin

A 
aptt 
inr
hbg
platelets
clinical signs of bleeding
64
Q

critical signs of bleeding*****

A 
melena (blood in stool) 
hematuria (blood in urine) 
ecchymosis (severe bleeding)
hematemesis (vomiting blood) 
hemoptysis (coughing blood) 
epistaxis (bleeding from nose) 
at least daily
65
Q

when would you use thrombolytic therapy for DVT/PE

A

pulmonary embolism with shock

massive dvt with limb gangrene

66
Q

why dont you just give lots of vit k to reverse warfarin effects for surgery

A

will take over a week for warfarin to work again

if try to reach inr after by increasing warfarin when the vit k wears off the inr will skyrocket

67
Q

for provoked vte how long and what target of warfarin

A

warfarin for 3 months

inr target 2.5

68
Q

for idiopathic vte how long should you use warfarin

A

more then 3 months

up to 2.5 years

69
Q

if a patient has thrombotic recurrence despite anticoagulation how should you continue warfarin

A

warfarin indefinately

inr target 3

70
Q

when else should you continue warfarin indefinitely

A 
patient has risk factors 
malignancy 
AT deficiency 
previous thromboembolism 
LV dysfunction
???
71
Q

which drugs should you avoid in patients with CrCl <30

A

LMWH
dabigatran
rivaroxaban
apixaban

72
Q

drug interactions with dabigatran *

A

inhibitors/inducers of p-gp

ex. amidarone, azithromycin, carvediol, diltiazem

73
Q

drug interactions of rivaroxaban and apixaban

A

inhibitors/inducers of p-gp and cyp 3A4

74
Q

drug interactions of LMWH

A

none known

75
Q

reversal agents for anticoagulant related bleeding – effectivenss is anticoagulant specific

A

protamine iv
bit k
fresh frozen plasma
recombinant factor VIIa (increased risk of thrombosis)
4 factor prothrombin complex concentrates

76
Q

which reversal agents arent really recommended for warfarin bleeding

A

rFVIIa
4-PCC
dialysis not effective in overdose

77
Q

what is idarucizuman

A

monoclonal antibody fragment specifically targeted at dabigatran

78
Q

when should you stop warfarin before surgery

A

1 week before surgery

79
Q

what is warfarin used to treat

A

major thrombosis

80
Q

time for full effects of warfarin

A

more than a week

81
Q

can you use warfarin in renal impairmetn

A

yup

82
Q

what is dabigatran rivaroxaban and apixaban used to prevent

A

stroke with a fib

83
Q

onset of dabigatran

A

1 hour full effects in 3 days

84
Q

when should you stop dabigatran, rivaroxabin, apixaban before surgery

A

1-2 days before

85
Q

what is effective and not effective for reversal in dabigatran

A

hemodialysis
rFVIIa
5g idarucizumab 1st line
not FFP or 4-PCC

86
Q

why isnt ffp used for dabigatran reversal

A

provides anticoagulation by inhibition not by depleting clotting factors

87
Q

what value does dabigatran increase

A

aPPT test

not recommended for monitoring

88
Q

which reversal agents are and arent effectiv ein rivaroxabin and apixaban

A

use 4-PCC

not dialysis or FFP

89
Q

whats a greenfield filter

A

mechanical device in the inferior vena cave to filter emboli originating from lower extremities

90
Q

who might be considered for green field filter

A

contraindication to anticoagulant theray

recurent pulmonary embolism despite anticoagulation

91
Q

counselling for LMWH, warfarin, DOACs

A

inform doctors and dentists of use
avoid asa and other nsaids
discuss new drugs or otc becuase many interactions
maintain normal diet despite vit k
medic alert bracelet
inr monitoring to ensure adequate coagulation
inform doctor promptly if clinical signs of bleeding

Clinical 2.0 (24 decks)

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